Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention—Observations

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To the Editor:
Re: Shoulder Dystocia Documentation: An Evaluation of a Documentation Training Intervention
Tammy LeRiche, MSc, MD, FRCSC; Lawrence Oppenheimer, MD, FRCSC, FRCOG; Sharon Caughey, MD, FRCSC; Deshayne Fell, MSc; and Mark Walker, MSc, MD, FRCSC. J Patient Saf, Volume 00, Number 00, Month 2014
We read with interest the article on shoulder dystocia documentation as related to a training intervention named MOREOB and wish to offer some background and further insight.
We wondered about the limitations of just reviewing the actual nursing and physician written notes to assess the overall quality of a maternal chart. Hospital charts contain multiple areas for entry of information on a birth, often requiring a health care professional to enter the same information repetitiously. The inclusion of all of the elements in Table 1 in a narrative note would be associated with the rewriting of the same information multiple times by the same people. Some of the infrequently documented elements in the written note identified in Tables 2 and 3 could likely have been found in the infant chart or in the standardized birth record. A study including all of the abovementioned documents would have produced a more robust source of data for comparison.
Be that as it may, we are puzzled by the conclusion of this article, which states, in part, “This study shows a general lack of improvement in the long-term quality and content of physician and nursing shoulder dystocia documentation after a training intervention.” A key element, indeed a key issue in shoulder dystocia cases, is the head-to-body delivery interval and its possible impact on permanent neurological injury and lower Apgar scores (The American College of Obstetricians and Gynaecologists. Task Force on Neonatal Brachial Plexus Palsy. Neonatal Brachial Plexus Palsy. 2014, 47). The simple fact that nurses' documentation of the head-to-body delivery interval increased by 88% (P < 0.0001) alone seems to contradict the authors' generalized conclusion. In addition, the physicians' quantitative narrative did improve (P < 0.003).
The MOREOB Program is a 3-year supported, structured culture change and patient safety program created by the Society of Obstetricians and Gynaecologists of Canada (SOGC). Although it includes many “traditional” tools such as up-to-date clinical content, simulations, workshops, and audits, to name but a few, the actual intervention lies in the unique layering of these tools along with support to lead a team to success. In that way, the program is much more than the simple sum of its parts; it is, to our knowledge, unlike any other in the world. All of its elements are delivered in a guided methodology to grow ownership within a frontline team. Once that ownership is developed, the team is able to effectively identify issues of importance to it and develop local solutions to those problems in real time (using tools within the program or developing their own)—thus increasing reliability in care.
Attempting to assess long-term improvement in documentation after isolating the 3-year program into only 1 of its component parts, a workshop event offered to each participant at 1 specific time point intrigued us, especially within the first year of the MOREOB intervention. At that early stage, most of the health care team would have seen this single workshop only as a traditional educational event, as opposed to the multidisciplinary team venue, where research evidence is challenged by practice experience to create what Zimmerman et al (Front-line Ownership: Generating a Cure Mindset for Patient Safety. Healthcare Papers. 2013;13:6–22) dubbed the “social proof” needed for positive deviance and, ultimately, for harmonizing of care to occur. The ownership develops over time as the health care team matures and settles into new behavioral change.

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